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Basal Cell Carcinoma on the Vermilion Lip: a Study of 18 Cases

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Basal Cell Carcinoma on the Vermilion Lip: a Study of 18 Cases Basal cell carcinoma on the vermilion lip: A study of 18 cases Sirunya Silapunt, MD,a S. Ray Peterson, MD,a Leonard H. Goldberg, MD, FRCP,a,b Paul M. Friedman, MD,a and Murad Alam, MDc Houston, Texas, and Chicago, Illinois asal cell carcinoma (BCC) involving the ver- milion border and mucosal surface of the lips B is rare, whereas these sites are more fre- quently involved by squamous cell carcinoma (SCC). The epithelium of the lip is divided into 4 regions: the skin; the vermilion border; the outer mucosa (vermilion); and the inner mucosa. The ver- milion border contains the orbicularis oris muscle without a subcutaneous fat layer. It is devoid of hair follicles and sweat glands. During the aging process the upper lip lengthens, the teeth wear down, and the angle of the jaw opens, resulting in a reduction in the amount of outer mucosa, which is exposed to the sun. We present 18 cases of BCC, which in- volved predominantly the vermilion lip. In our study, we use the term “vermilion lip” to include the vermilion border and the outer mucosal surface of the lip (Fig 1). The clinical presentation and histo- pathology of these cases were reviewed and char- acterized. (Figs 2-7). Fig 1. Vermilion lip. MATERIALS AND METHODS We reviewed 18 cases of BCC on the vermilion lip diagnosed from October 1997 to October 2002 in a private Mohs micrographic surgery referral practice in Houston, Texas. There were 7027 cases of his- topathologically confirmed BCC in that period. Only BCCs involving predominantly the vermilion lip were included in the study. These patients were called and asked about recurrence and a history of sunscreen use, cold sores, and smoking at the time From the DermSurgery Associates, Houstona; Department of Medicine (Dermatology), University of Texas, M. D. Anderson Cancer Center, Houstonb; and Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago.c Funding sources: None. Conflicts of interest: None identified. Fig 2. Number of cases of basal cell carcinoma of vermil- Reprint requests: Leonard H. Goldberg, MD, DermSurgery ion lip by anatomic site. Associates, 7515 Main St, Suite 240, Houston, TX 77030. E-mail: [email protected]. J Am Acad Dermatol 2004;50:384-7. 0190-9622/$30.00 of the study. Cases of BCC primarily involving the © 2004 by the American Academy of Dermatology, Inc. skin surface around the lip with an extension to the doi:10.1016/j.jaad.2003.08.027 vermilion border were not included in this study. 384 JAM ACAD DERMATOL Silapunt et al 385 VOLUME 50, NUMBER 3 Table I. Age and sex of patients, previous skin cancers, site of basal cell carcinoma, lymph-node involvement, and treatment No. of cases 18 Average age (y) 64 (36-87) F60 M68 Sex M: F 1:1 Previous skin cancer (BCC or SCC) at 15 other sites (cases) Site (cases) Upper vermilion lip 14 Lower vermilion lip 4 MMS (cases) 18 Number of MMS staging required for 2.55 (1-7) Fig 4. Superficial basal cell carcinoma attached to lower tumor extirpation surface of mucosal epithelium. Clefting and mucopolysac- Lymph-node involvement (cases) 0 charide surrounding tumor cells is shown. (Toluidine blue Wound closure (cases) stain; original magnification ϫ40.) Simple closure 11 Flap or second intention 7 BCC, Basal cell carcinoma; F, female; M, male; MMS, Mohs micro- Table II. Invasion of deeper structures graphic surgery; SCC, squamous cell carcinoma. Cases Invasion of various structures (18) None 12 Invasion Perineural infiltration 1 Perineural and muscular infiltration 3 Perineural, perivascular, and muscular infiltration 2 was 38 months (4-67 months). A history of smoking, Fig 3. Basal cell carcinoma on vermilion lip of 45-year-old sunscreen use, and cold sores were obtained (Table woman. III). DISCUSSION RESULTS The distribution of malignant tumors of the lips is In all, 7027 cases of BCC at all body sites were usually sharply divided between SCC of the lower diagnosed histopathologically during the 5 years. Of lip and BCC of the upper lip. The lower vermilion lip these, 18 (0.25%) were centered on the vermilion lip. is subjected to intense sun exposure and is the most The distribution of the BCCs in this study is illus- common site of origin for SCC. In our study, 14 of trated in Fig 2. The clinical characteristics of the the 18 cases of BCC were on the upper vermilion lip. patients are shown in Table I. The clinical diagnosis If the histogenesis of BCC was entirely actinic or was accurate in 17 of 18 cases. One case was clini- solar-related, one would have expected to see the cally diagnosed as an SCC but was shown to be a distribution of the tumor more in favor of lower BCC histopathologically. A total of 3 patients pre- vermilion lip. The precise histogenesis of BCC on sented with BCC on the vermilion lip as their first the vermilion lip is not clear. The concept of its skin cancer (Fig 3). Histopathologically, the tumors origin from the pluripotential epithelial cells of the were either superficial, infiltrative, nodular, or mor- squamous mucosa and epidermis has been postu- pheic types (Fig 4). There was evidence of tumor lated.1,2 Their origin from a heterotopic sebaceous infiltration of the nerve, muscle, or vessels in 6 of the gland or a primary epithelial germ may be consid- 18 cases (Table II and Figs 5 through 7). ered.3 The other possibility of origin may be from We were able to contact 15 of the 18 patients at traumatic epithelial implantation.4 the period of this writing. There were no recurrences A limited number of BCCs involving primarily the in any of the 15 cases. The average follow-up time vermilion border or outer mucosal surface of lip 386 Silapunt et al JAM ACAD DERMATOL MARCH 2004 Fig 5. Small groups of basaloid cells infiltrating perivas- Fig 7. Basal cell carcinoma cells surround small nerve on cular space of inferior labial artery. (Toluidine blue stain; lower lip. original magnification ϫ40.) Table III. History of smoking, sunscreen use, and cold sores Cases At the time of diagnosis (15) History of smoking Nonsmoker 10 Ex-smoker 4 Smoker 1 History of sunscreen use 1 History of cold sores 7 Table IV. Previously reported cases of basal cell carcinoma on the vermilion lips Fig 6. Small groups of basal cell carcinoma infiltrating orbicularis oris muscle. (Toluidine blue stain; original Reported magnification ϫ20.) Authors Year cases Site Welton et al5 1949 2 Mucosal surface Keen and Elzay4 1964 1 Vermilion border and have been reported (Table IV). In 1949, Welton et mucosal surface 5 al found 2 cases of BCC on the mucosal surface of Weitzner and Heutel7 1968 1 Vermilion area the lower lip among 620 cases of BCC at all sites. In Weitzner3 1975 3 Vermilion mucosa 1975, a retrospective review of 652 cases of BCC Kelly et al8 1975 1 Vermilion border indicated that there were 3 cases of BCC on the White et al9 1980 1 Vermilion border vermilion mucosa.3 In 2001, 6 cases of BCC on the 1 Mucosal surface vermilion border of the lip were found from a re- Hume and Turner10 1982 1 Mucosal surface view of 3477 cases of BCC diagnosed in a period of Oriba et al11 1998 3 Vermilion area 6 11 years.6 de Sousa et al 2001 6 Vermilion border BCC of the lips usually presents with ulceration or bleeding. The differential diagnosis of ulceration of the lip is shown in Table V. The ulceration and BCC of the vermilion lip is rare. In this location, bleeding from BCC of the lips are commonly inter- the tumor appears to originate at the vermilion bor- mittent; much like that seen in herpes simplex. The der and invades onto the rest of the vermilion lip. most frequent diagnosis of ulceration of the lip is The contiguity of growth of BCC on the vermilion herpes simplex. It is not unusual for BCC of the border onto the mucosal surface of the lip was lower lip to be initially diagnosed and treated as clearly demonstrated from sequential Mohs layers in herpes simplex, acute or chronic. our cases. JAM ACAD DERMATOL Silapunt et al 387 VOLUME 50, NUMBER 3 Table V. Differential diagnosis of ulceration of REFERENCES the lip 1. Williamson JJ, Cohney BC, Henderson BM. Basal cell carcinoma of the mandibular gingival. Arch Dermatol 1967;95:76-80. Herpes simplex 2. Macomber WB, Wang MKH, Sullivan JG. Cutaneous epithelioma: Aphthous ulcer a study of 853 lesions. Plast Reconstr Surg 1959;24:545-62. Actinic cheilitis 3. Weitzner S. Basal cell carcinoma of the vermillion mucosa and Basal cell carcinoma skin of the lip. Oral Surg Oral Med Oral Pathol 1975;39:634-7. Squamous cell carcinoma 4. Keen RR, Elzay RP. Basal cell carcinoma from mucosal surface of Trauma lower lip: report of a case. J Oral Surg 1964;22:453-5. Burn, bite, bumps, and factitial cheilitis 5. Welton DG, Elliott JA, Kimmelstiel P. Epithelioma: clinical and Lichen planus histologic data on 1025 lesions. Arch Dermatol 1949;60:277-93. Contact cheilitis 6. de Sousa JD, Yus ES, Rueda M, Rojo S. Basal cell carcinoma on the vermillion border of the lip: a study of six cases. Dermatology 2001;203:131-4. BCC invasion to deeper structures of the lips 7. Weitzner S, Heutel W. Multicentric basal cell carcinoma of ver- occurs early and is common in these cases. This million mucosa and skin of lower lip: report of a case. Oral Surg could be explained by the proximity of the nerve Oral Med Oral Pathol 1968;26:269-72.
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